Module 16 Genitourinary Surgery PDF

MODULE 16: Genitourinary Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 15 Tighe (2015) Instrumentation for the Operating Room Chapter 25, 28, 31,...

MODULE 16: Genitourinary Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 15 Tighe (2015) Instrumentation for the Operating Room Chapter 25, 28, 31, 33 ORNAC Standards 2023 Learning Outcomes Describe the genitourinary (GU) anatomy. Explain surgical interventions and procedural considerations for open and closed GU surgeries, scrotal surgery, prostate surgeries and kidney surgeries. Advances in genitourinary (GU) surgery, with the use of robotics, laparoscopic techniques, lasers, lipotripers and MIS approaches has expanded surgical treatment options for the GU patient. Anatomy Kidneys Kidneys are composed of tissue in the outer part and a renal pelvis (where urine collects) in the central part. Located retroperitoneal The right kidney is several centimeters lower than the left kidney because the liver rests superior and anterior to the right kidney Highly vascular organ processing 1/5th of the body’s entire blood volume at one time Blood supply directly off the aorta, to renal artery drainage is through the renal vein Kidney transplantation from a live donor – The Left kidney is usually removed because the left renal vein is longer than the right renal vein. This improves implantation outcomes. However, in some cases, the right may be removed if there are anatomical issues in the recipient. Ureters The ureters are 25 – 30 cm and 4 – 5mm in diameter (adult) Extends from the renal pelvis to the base of the bladder The upper ureter is supplied by the renal artery and by branches from the gonadal artery and aorta. Urinary Bladder A hollow, muscular viscus that acts as a reservoir for urine until voiding occurs Module 16: Urology  Located extraperitoneal Blood supply to the bladder is by the superior, middle, and inferior vesical arteries, which arise directly or indirectly from the internal iliac artery. Venous rich blood supply that drains into the internal iliac vein. Urethra Male urethra - 20-25 cm long Female urethra - 4 cm long – greater risk for urinary tract infection (UTI) due to short urethra and proximity to anal and vaginal areas Cystoscopies, Transurethral Resection of Prostate (TURP), and Ureteric stents are inserted via the urethra Prostate Gland It is a donut shaped gland located at the base of the bladder neck and completely surrounds the urethra Divided in 4 glandular regions Referred to as intraurethral lobes (right and left lateral) and extraurethral lobes (posterior and median) Male Reproductive Organs Paired structures: testes, epididymis, seminal ducts (vas deferens), seminal vesicles, ejaculatory ducts, Cowper’s glands (bulbourethral glands) Singular structures: penis, scrotum Adrenal Glands Retroperitoneally located and made of two main parts: Adrenal Cortex and Adrenal Medulla Medulla secretes adrenaline Cortex secretes steroids and hormones that are influenced by the pituitary gland Blood supply- same as kidney plus arterial branches of the inferior phrenic artery Perioperative Nursing Considerations Nursing Assessment Urologic procedures frequently require positions that create stress for the patient. Anatomic and physiologic considerations, such as compression of the vena cava and dependent lung during lateral positioning need to be considered. In addition, large amounts of irrigating fluids are often used so a thorough lab and electrolyte assessment is imperative. Module 16: Urology Blood Replacement - Patients may require extensive tissue dissection in highly vascular areas, resulting in the need for blood transfusion. Orders and availability of blood products must be confirmed pre-, intra-, and post-operatively. The RPN should be prepared in the scrub role with hemostatic agents, such as hemoclips, sutures, ties, sponges, Gelfoam, Surgicel, etc to anticipate any critical surgical needs. Patient Positioning - The surgical procedure determines the patient’s intraoperative position. Typically, a patient undergoing GU surgery will be placed one of the four positions: 1) supine open cases, 2) supine with Trendelenburg tilt to access the urologic organs, 3) lithotomy for cystoscopy, Trans Urethral, and laparoscopic surgeries, 4) lateral for kidney surgeries. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. Other positioning devices, such as bean bags and bolsters, may be used for lateral position. The patient position and the associated positioning devices may vary depending on the surgeon’s preferences and available institutional resources and policies. It is recommended that the perioperative nurse collaborates with the surgical team to ensure that the patient is positioned safely before, during, and after surgery. The perioperative nurse ensures that the patient return electrode pad is applied and the safety strap secured. When patients are placed in lithotomy position, stirrups are used. The perioperative nurse must ensure the stirrups are fastened to the bed to support the patient’s legs. Hips should not be flexed greater than 90 degrees to prevent injuries to the sciatic and obturator nerves as well as hip joint and muscle strains. Removing the legs from the stirrups after surgery is a slow and coordinated process requiring adequate support from others. Lower the legs slowly to facilitate hemodynamic adjustment when blood shifts to lower extremities. This also prevents lumbosacral muscle strains. Instrumentation and Counting GU surgeries can be open, MIS, or a combination Cystoscopy, Ureteroscopy, Urethoscopy (MIS): Cystoscopy set up Single tubing for irrigation (1000ml Saline Bag) – Closed system Light cord Two main types of scopes: o Cystoscopes o Resectoscopes No count required Module 16: Urology Nephrectomy (Open and Laparoscopic), Prostatectomy (Open and Laparoscopic), Cystectomy (Open), Pyeloplasty (Open) Basic laparotomy set, including short and long instruments Prostate and bladder instrument extras Kidney Instruments and Rib resection specialty instruments A large abdominal retractor eg. bookwalter retractor Foley catheters on sterile set up A major count is conducted at the beginning of all cases, and a small or minor count for final count Initial Count (major) → Closing Count (major) → Final Count (minor) Equipment Intra-operative Fluroscopy (C-arm) – Ensure patient is placed on a OR bed compatible with fluoroscopy. Whenever possible, the patient should be protected from undue radiation exposure to the thyroid and chest areas by using small leaded shields. Shielding reproductive organs in GU surgeries is not feasible. Lasers (Holmium Yag, Yag KTP Green Light) – Apply appropriate safety precautions and knowledge of laser Protocols. Ureteral and Urethral Catheters - will be used for specific surgeries. The most commonly used catheters include the open-ended, whistle tip, cone tip, and olive tip. In some surgeries, not just urologic, ureter catheters may be inserted as stents so that the structures can be identified during pelvic dissections and prevent accidental cutting. Operating Room Table – Urological tables have special equipment, allowing for X- ray capability, photographic ability, and drainage screens to catch specimens and still let the irrigating fluid run through. Irrigation Fluids – When the bladder is entered, sterile distilled irrigation fluid is administered to distend it for effective visualization. Irrigating fluids should be used with closed systems to prevent the inherent risks of cross-contamination, such as “Cysto-tubing” and looks similar to IV lubing with a much larger diameter. Large volumes will be used for more extensive MIS surgeries. The fluid should be warmed through a warming unit to reduce the risk of hypothermia (cold fluids entering the patient’s warm body). Module 16: Urology  Normal Saline is a safe fluid for simple observational cystoscopy, bladder tumour fulgurations (a light superficial burning) and retrograde pyelography. Sterile Water is used for simple procedure that require the use of monopolar cautery where high absorption into the bloodstream is not anticipated. A clear, nonelectrolytic, and iso-osmotic solution, such as Sorbitol, Cystosol, and Glycine should be used for transurethral resection of the prostate (TURP), as venous sinuses may be opened and varying amounts of irrigants are invariably absorbed into the bloodstream. Studies indicate that the use of sterile water during TURP may result in hemolysis of erythrocytes and possible renal failure. **Also dilutional hyponatremia and potential cardiac decompensation. Cystoscopes – Used for simple observational diagnoses, but with accessories, can do many other procedures such as retrograde pyelography, retrieve stones in the bladder/ureters, insert stents, and fulgurate bladder tumours. Flexible Cystoscope Rigid Cystoscope Resectoscopes are special scopes that have cutting loops inside them that are electrically- powered (similar to the hysteroscope resectoscope for endometrial ablations). Surgical Interventions Cystoscopy (Flexible and Rigid) - An endoscopic examination for direct vision of the urethra into the bladder. If a stricture is detected in the urethra, then a dilation or an internal urethrotomy may be done along with a cystoscopy. Retrograde Pyelogram - An imaging test that uses X-rays to look at the bladder, ureters, and kidneys. Usually done during a cystoscopy and can be done with local anesthetic injected into the urethra eg. xylocaine gel. Catheter will be inserted in one or both ureters and the dye solution will be injected through the catheter for visualization. Prostate Surgery Module 16: Urology Transurethral Resection of the Prostate (TURP) – Performed for benign prostatic conditions - very common in elderly men. Only the prostate tissue is taken, not the capsule. A nonelectrolytic ionic medium (Cystosol, Mannitol, Glycine) is used with the monopolar cautery. These solutions are kept cold in the fridge, therefore require careful monitoring of the patient for signs of hypothermia when used. The return of irrigation fluid must be monitored because intravasion and absorption of fluid into open prostatic venous sinuses (or bladder perforation with TUR of Bladder tumour) may occur. Signs and Symptoms of Irrigation Fluid Overload Respiratory changes, bradycardia, hypertension followed by hypotension, abdominal discomfort, nausea and vomiting, and severe agitation. This could lead to hypervolemia and hyponatremia. If these signs and symptoms occur the procedure is stopped, followed by a cystogram to determine if there is a bladder perforation. A Foley catheter will be inserted and the patient is further monitored in the recovery room area. A 3-way Foley with a 30cc balloon is inserted and pulled taut to make the balloon compress the resected prostatic tissue for hemostasis. Transurethral Ureteropyeloscopy (TUR) for Bladder Tumour – Endoscopic examination of the ureters and renal pelvis. Signs and Symptoms of irrigation fluid overload are monitored. The irrigation fluid for TUR of bladder tumours is sterile water. The rational for this is few vessels are uncovered during this short resection procedure. Water absorption issues does not occur. Open Prostate Surgery - For enlarged benign prostate or cancer, common in men age 50 years and up. Prostatectomies includes the excising of the prostate gland, capsule and seminal vesicles. The surgeon determines the appropriate approach (open versus minimally invasive) depending where the cancer is located. Suprapubic Prostatectomy - Prostate is removed through a transvesicle approach as the tissue is obstructing the outlet of the urinary tract. This direct approach allows the surgeon access to fix any existing bladder conditions at the same time as removing the prostate. Bleeding is a major concern for all open prostatectomies. The prostate lies behind the symphysis pubis and ligating bleeding vessels can be difficult. Simple Retropubic Prostatectomy - Allows excellent exposure of the prostate bed and vesicle neck. Intraoperative bleeding is easily controlled with this approach and the one of choice, if possible. Prostate gland is removed and prostatic capsule is closed (absorbable sutures). Nerve Sparing Radical Retropubic Prostatectomy with Pelvic Lymphadenectomy - Preferred treatment for patients with organ-confined carcinoma of the prostate. It removes the entire gland, the capsule, and the seminal vesicles. Important structure involving erectile function are within the surgical field and thus the title “nerve sparing” as the surgeon does the best possible for the patient to prevent damage to these vessels and nerves. Additional considerations will include removal of pelvic lymph nodes to determine how advanced the cancer is. If cancer is too advanced, the surgeon will close and adjunct therapy will be considered. Module 16: Urology Minimally Invasive Radical Prostatectomies Robotic Laparoscopic Radical Prostatectomy – Uses robotic equipment to imitate the surgeon’s movements, allowing for operative access through five small portal incisions, resulting in shorter recovery time. Enhances the surgeon’s range of motion and precision, allowing the preservation of nerves crucial to urinary continence and erectile function. Laparoscopic Radical Prostatectomy – Preferred approach compared to open procedure due to decreased intraoperative blood loss, shorter hospital stays, and decreased post-operative pain. Abdominal insufflation is achieved with the verres needle, and a 10mm trocar is inserted. Additional 5mm ports (x3) are inserted. Bladder filling occurs through Foley to distend and show contours of the bladder Bladder Surgery Bladder surgeries can be done through an open abdominal or transurethral approach. Diagnostic testing is usually transurethral, while bladder tumours, congenital defects, and trauma may necessitate an open abdominal approach. Supra Pubic Cystostomy – An opening made into the urinary bladder through a low abdominal incision and a drainage tube is inserted into the bladder. TUR (transurethral resection) of Bladder Tumours – Removal of lesions using a standard resectoscope, which is passed through the urethra into the bladder. Radical Cystectomy with Pelvic Lymphadenectomy - Cystectomy is the total excision of the urinary bladder and adjacent structures along with pelvic lymph nodes. This procedure is indicated when the tumour has invaded the muscular wall of the bladder. When a cystectomy is done, another receptacle is required to act as the bladder with an opening or stoma that acts as the urethra. The reservoir created is called an “Ileal Conduit”. Once the bladder is removed, the urine flow is permanently diverted into a new bladder created in an isolated loop of the bowel (a piece of ileum). The ureters are then transplanted into the piece of bowel. A section of the ileum proximal to the ileocecal valve is used to create a stoma. This one-way valve will keep the urine in the bladder until the patient does a self-catheterization to remove the urine. This is called a continent ileostomy or a “Kock Pouch”. The total excision of the bladder includes adjacent structures, pelvic lymph nodes, a prostatectomy in men, and a hysterectomy in women. Module 16: Urology  Ureteral Surgery Stones, infections, and tumours are the most common cause of urinary tract obstruction, necessitating surgery to prevent renal obstruction and subsequent renal failure. MIS approach for stone removal - A lithotripsy probe (stone basket) is inserted through a cystoscope into the bladder and up the ureter where the stone is lodged where the probe activates the laser to remove the stone. This is done under x-ray control. If the stone cannot be removed this way, a lithotripsy may be done. Ureterostomy/ Ureterotomy- Opening the ureter for continued drainage into another body part. This open surgery is done to excise stones in the ureter that cannot be excised through MIS. Ureterectomy - Removal of the complete ureter. May be part of a nephrectomy or for a cancerous tumour. Ureteroureterostomy - Removal of a segment of/or a diseased portion of the ureter with reconstruction in continuity of the two normal segments. This is often seen in pediatrics when a congenital defect is present. Ureteroentersotomy - A diversion of the ureter into a segment of the ileum (commonly referred to as ileal conduit) in urinary diversion surgery. Ureterolithotomy - Opening the ureter to remove an obstructing stone/calculus. Kidney Surgery Nephrostomy - Creation of an opening into the kidney to maintain temporary or permanent urinary drainage. Nephrotomy – Incision into the kidney. Pyelolithotomy - Removal of a calculus through an opening in the renal pelvis. Module 16: Urology Pyelostomy - Making an opening into the renal pelvis for temporary or permanent diversion of the flow of urine. Pyelotomy - Incision into the renal pelvis usually to remove a stone. Percutaneous Nephrolithotomy with Lithotripsy - Removal or disintegration of renal stones using a rigid or flexible nephroscope under x-ray control. May require use of ultrasound, lithotripter probe, or laser Open Nephrectomy – The surgical removal of a kidney. It is performed for congenital hydronephrosis, renal tumour, renal trauma, calculi disease or renovascular hypertension. If necessary, the 11th or 12 rib will be resected. The kidney is isolated and major vessels are double clamped, triple ligated, divided, and tied with heavy non absorbable ties (silk). *Radical nephrectomy is usually for cancer and the entire kidney, adrenal gland, perirenal fat, Gerota capsule, and para-aortic nodes are removed. Laparoscopic Nephrectomy – The surgical removal of a kidney using a laparoscopic approach for benign disease. The procedure always includes a cystoscopy with placement of a renal balloon catheter, a ureteral catheter, and a foley urethral catheter under fluoroscopy (Patient and staff must wear x-ray protective coverings). Kidney Transplantation Kidney transplant entails transplantation of a living-related or cadaveric donor kidney into the recipient’s iliac fossa. It is performed in an effort to restore renal function and thus maintain life in a patient who has end-stage renal disease. Transplant from a Living Donor (Nephrectomy) Two adjacent ORs are used: the donor surgery is a nephrectomy and begins before that of the recipient’s so that the suitability of the vessels can be verified. Often done Laparoscopically The Left kidney is usually removed because the left renal vein is longer than the right renal vein. This improves implantation outcomes. Transplant from a Cadaveric Donor Potential donors are young, free from infection and cancer, normotensive until a sort time before death, and under hospital observation several hours before death. These donor patients include trauma where the patient came to the ER with signs of life. The patient is then intubated and put on a ventilator where they are monitored to see if they’ve suffered ‘brain death.’ It must be known that the oxygenation of the donor was not interrupted for more than 5 minutes. The text only mentions brain death (neurological death) but now in Ontario there is another criterion called Donation after Cardiac Death (DCD). Module 16: Urology Transplant into Live Recipient The transplant recipient requires optimal nutritional support and dialysis. During surgery, the patient’s native kidneys are often NOT removed. An extra table is required with a sterile set up for the kidney. It will be in a large basin of iced saline and University of Wisconsin solution compatible for preserving the kidney. The surgeon performs the anastomosis of the donor kidney renal vein to the side of the recipient’s iliac vein, and the donor renal artery to the recipient internal iliac artery. Testicular Surgeries Hydrocelectomy – An excision of the tunica vaginalis of the testis to remove an abnormal accumulation of fluid. The procedure is performed via a scrotal incision. The cause is usually an infection or trauma. Orchidopexy - Surgical placement and fixation of the testicle in a normal anatomical position in the scrotal sac for an undescended testicle in the pediatric patient. Orchiectomy - Removal of a testis or testes. This can be done unilateral or bilateral for trauma, cancer or infection. The approach can be scrotal or inguinal depending on the patient, and may also be performed laparoscopically. Radical Lymphadenectomy (Retroperitoneal Lymph Node Dissection) – Bilateral resection of retroperitoneal lymph nodes, includes: lymph nodes, channels, and fat around both renal pedicles; the vena cava; and the aorta. Module 16: Urology